Introduction

Enhancing visualization within the oral cavity has long been a goal of dental practitioners. External lighting sources, patient positioning, and the use of mirrors have been employed since the onset of modern dentistry. However, as the complexity of dental and oral surgical procedures increases and as more advanced magnification tools become available, the adoption of tools to improve visualization has become more and more commonplace. Modern magnification and visualization aids can be utilized to improve clinical outcomes, enhance dental healthcare providers comfort and productivity, and improve the post-operative healing after periodontal procedures. Magnification loupes, microscopes, and enhanced visualization through the use of endoscopic visualization have been associated with enhanced outcomes of most technical dental procedures.^{[1,](/en-us/ce-courses/ce653/references#1)[2](/en-us/ce-courses/ce653/references#2)} Given the importance of mere millimeters of hard and soft tissue in periodontal regenerative procedures and the challenges with adequate root debridement in closed scaling and root planing, it has been proposed that the use of enhanced visualization techniques are uniquely suited to improve nonsurgical and surgical periodontal procedures.

Periodontitis is a common chronic infectious-inflammatory condition.³ The primary etiology of periodontitis is dental plaque biofilm and bacterial-associated virulence factors.^4-6 These factors initiate a host immune response that results in the destruction of the hard and soft tissues supporting the teeth, this response is moderated by genetic, environmental, and acquired risk factors.^4-6 Initial periodontal treatment focuses on the effective and regular removal of the dental plaque biofilm and any secondary plaque retentive factors, such as dental calculus as well as host modulation and risk reduction strategies for periodontal disease modifying factors.^4-6 Adequate removal of primary etiologic factors is critical to achieving optimal periodontal health.^4-9 The long-term outcome of periodontal therapy, both nonsurgical and surgical, relies upon removal of the biofilm and elimination of periodontal pathogens associated with the tooth surfaces, periodontal tissues, mucosal surfaces, the tongue dorsum, and other niches within the oral cavity as well as the prevention of re-infection by exogenous and endogenous pathogens.^4,6 Nonsurgical periodontal therapy aims to establish a root surface that is biologically acceptable for the reestablishment of a healthy periodontal attachment,^10-13 but this can be a challenge in areas where visualization cannot be reliably achieved and access for debridement is limited. These areas may include deep periodontal pockets, root flutes, root concavities or other anatomic limitations, and the cemento-enamel junction (CEJ).^14-17 It is well-established that surgical flap reflection to allow for enhanced visualization improves the efficacy of root surface debridement and may account for improved clinical outcomes after surgical treatment at some sites.¹⁸ While surgical debridement may improve biofilm and calculus removal, there are limitations and adverse outcomes of periodontal surgery in some instances. Increased gingival recession and esthetic compromise as well as post-operative discomfort and dentinal hypersensitivity (DH) are all common sequelae after periodontal surgery.¹⁹ To reduce morbidity associated with surgical interventions and improve the outcomes of nonsurgical periodontal therapy many therapies have been proposed for use in practice, including the use of laser-assisted periodontal debridement, subgingival irrigations, local delivery of antimicrobial therapies, and enhanced visualization techniques. Specifically, enhanced visualization techniques, including the use of loupe magnification, microscopy, and periodontal endoscopy have been proposed as methods to avoid or limit surgical access in certain clinical scenarios. In addition, surgical techniques may be employed to repair defects caused by periodontal disease progression and acquired or innate mucogingival deformities. This course will review the adjunctive use of enhanced visualization protocols during the treatment of periodontal diseases and conditions.